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Closure of atrial septal defects: The good, the bad and the ugly?
Atriyal septal defektlerin kapat›lmas›: ‹yi, kötü ve çirkin?
Following the initial successful report of non-surgical trans-catheter closure of atrial septal defect (ASD) (1), various devi-ces have been developed over the past 2 decades (2-8). Howe-ver, most of them require large delivery sheaths and complex deployment techniques, and have significant residual shunt. Alt-hough the adult cardiologists are using these devices widely, in many pediatric cardiac institutions surgical closure is reserved for the patients whose families choose surgical repair or whose lesion remains unsuitable for device closure (9-11). This is also may be due surgical closure of ASD still has a high success ra-te, with low morbidity and favourable long-term outcome (12,13). There are many questions about ASD closure: 1)When sho-uld it be closed? 2) How shosho-uld it be closed? 3) What is the cost effectiveness of these techniques? and 4) What are the long-term results of transcatheter techniques?
We know the answer of the first question nearly complete but the answers for the rest still waiting in this debate.
In this issue of The Anatolian Journal of Cardiology we will read a large retrospective clinical study (14) about transcathe-ter closure of ASD, which is performed on pediatric patients by Amplatzer device.
Although this study is important as it presents the clinical experience with transcatheter occlusion of a large series of ASDs in our country, there are some doubts about indications and the technique. Amplatzer device seems successful in clo-sing ASDs in children, because of its simplicity in applying the device, low rate of residual shunting (2.5%) and requirement for smaller introducer sheaths. However simplicity of the method should not change the indications of ASD closure. Indications of ASD closure are same both for surgical and transcatheter clo-sure and the criteria are as follows: Qp/Qs ratio greater then 1.5, right atrial, right ventricular enlargement, incomplete bundle branch block on electrocardiogram and clinical symptoms, ef-fort capacity and paradox embolism in adult population.
To close small ASD’s, which do not fulfill the above criteria, either surgically or with a device, is a topic of continuing discus-sion. Our policy is to close the ASD’s, which fulfill the above cri-teria.
Although there are several reports about the successful clo-sure of ASDs with a device there are some unfavorable reports in the recent literature about the device closure. Twenty-four cases with cardiac perforation due to Amplatzer device have been reported recently (15). Also there are some reports about thrombus formation in the left atrium, right atrium or both in 35 cases among 1000 patients with ASD devices (16). This report brings the question about anticoagulation. What is the approp-riate time to stop the anticoagulation? After six months throm-bus formation was reported to be 0% for Cardioseal, Starflex,
ASDOS and Helex devices, and 0.3% for Amplatzer device. It se-ems that epithelization of the device takes more than six months (17). Further long-term studies may bring answers to the above questions. One of the problems concerning ASD devices is the cost-effectiveness, especially for the developing countries as it is cheaper to close ASDs surgically.
In conclusion, Amplatzer ASD occluder is the mostly accep-ted ASD closing system in the world, because of its simplicity in application. Yet this procedure has not achieved wide-spread use because of some handicaps mentioned above and new de-vices are being produced or improved everyday. Having good devices should not stop the further studies to get the best.
Rana Olguntürk
Department of Pediatric Cardiology
Medical Faculty, Gazi University
Ankara, Turkey
References
1. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome af-ter surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years. N Eng J Med 1990;323:1645-50.
2. Rashkind WJ, Cuaso CE. Transcatheter closure of atrial septal de-fects in children. Eur J Cardiol 1977; 8: 119 – 20.
3. Rashkind WJ. Transcatheter treatment of congenital heart dise-ase. Circulation 1983; 67: 711 – 6.
4. Lock JE, Rome JJ, Davis R, et al. Transcatheter closure of atrial septal defects. Experimental studies. Circulation 1989; 79: 1091 – 9. 5. Sideris EB, Sideris SE, Fowlkes JP, et al. Transvenous atrial septal defect occlusion in piglets with a ‘buttoned’ double-disk device. Circulation 1990; 81: 312 – 8.
6. Babic UU, Grujicic S, Popvic Z, et al. Double umbrella device for transvenous closure of patent ductus arteriosus and atrial septal defect. First clinical experience. J Interv Cardiol 1991; 4: 283 – 94. 7. Das GS, Voss G, Jarvis G, et al. Experimental atrial septal defect
closure with a new, transcatheter, self-centering device. Circula-tion 1993; 88: 1754 – 64.
8. Pedra CA, Pihkala J, Lee KJ, et al. Transcatheter closure of atrial septal defects using the Cardio-Seal implant. Heart 2000; 84: 320 – 6. 9. Berger F, Vogel M, Alexi-Meskishvili V, Lange PE. Comparison of results and complications of surgical and Amplatzer device closu-re of atrial septal defects. J Thorac Cardiovasc Surg 1999;118:674–8.
10. Wilkinson JL. Can transcatheter closure of atrial septal defect be regarded as a “standard” procedure? Cardiol Young 1999;9: 458–61.
11. Rao PS. Transcatheter closure of atrial septal defect: are we the-re yet? J Am Coll Cardiol 1998;31:1117–9.
Address for Correspondence : Prof. Dr. Rana Olguntürk, Gazi Üniversitesi T›p Fakültesi, Çocuk Kardiyoloji Bilim Dal›, 06500 Beflevler – Ankara
Tel: 0 312 2024444, rana@gazi.edu.tr
12. Meijboom F,Hess J,Szatmari A, et al. Long-term follow-up (9 to 20 years) after surgical closure of atrial septal defect at a young age. Am J Cardiol 1993;72:1431–4.
13. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome af-ter surgical repair of isolated atrial septal defect. N Engl J Med 1990;323:1645–50.
14. Çeliker A, Özkutlu S, Karagöz T, Ayabakan A, Bilgiç A. Transcathe-ter closure of inTranscathe-teratrial communications with amplatzer device: results, unfulfilled attempts and special considerations in children and adolescents. Anadolu Kardiyol Derg 2005: 5; 159-64.
15. Divekar A, Gaamangwe T, Shaikh N, Raabe M, Ducas J. Cardiac perforation after device closure of atrial septal defects with the Amplatzer septal occluder. J Am Coll Cardiol 2005; 45:1213-8. 16. Krumsdorf U, Ostermayer S, Billinger K, et al. Incidence and
clini-cal course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients. J Am Coll Cardiol 2004;43:302–9.
17. Chessa M, Butera G, Frigiola A, Carminati M. Endothelialization of ASD devices for transcatheter closure: possibility or reality? Int J Cardiol 2004; 97: 563-4.
Dr.Meral Egüz
Anadolu Kardiyol Derg 2005; 5: 165-6 Rana Olguntürk
Closure of atrial septal defects: The good, the bad and the ugly?
